Service Plan Implementation, Client Contact, Monitoring, and Follow Up

The bulk of case management work occurs in the implementation of the service plan. For Brief and Comprehensive Service Plans, implementation involves carrying out of tasks listed in the plan, including the following activities:

provider contact in person, by phone, or in writing

assistance to client and collaterals in applications for services or entitlements

assistance in arranging services, making appointments, confirming service delivery dates

encouragement to client/collaterals to carry out tasks they agreed to

direct education to the client/collaterals as needed

support to enable client/collaterals to overcome barriers and access services

negotiation and advocacy as needed

other case management activities as needed by client, and as expected and permissible by program initiative.

In general the type and frequency of contact should be based on client needs. However, some individual AIDS Institute initiatives may establish minimum requirements for frequency and type of case management contact by providers.

In the Comprehensive Case Management Model, client contact and monitoring are expected to be frequent and proactive in order to anticipate problems, stabilize the client's status, prevent crises, and support the client in achieving service goals. Expectations include face-to-face contacts, home visits, and accompaniment of clients to providers where necessary to ensure service acquisition.

In the Supportive Case Management Model, at a minimum, client contact and monitoring is required to follow up on referrals, determine the status of service acquisition, and to assess whether the client has further needs requiring additional case management services.

Standard

Criteria

Provision of case management services outlined in the Brief or Comprehensive Service Plan proceeds immediately after its completion.

Clients are contacted based on their level of need. Client status is monitored. Case management staff follows up to determine receipt of service.

Comprehensive and Supportive Case Management models

Frequency and type of client contact may be established by individual AIDS Institute initiative.

Oversight of service plan implementation is the responsibility of the case manager.

Progress notes in the case management record detail the advancement of the case management effort for client and collarterals and record actual outcomes of activities.

Evidence is documentated in the client's chart that the case manager and/or team members contact the client and/or providers by a means and frequency appropriate to the client's needs, or according to AIDS Institute initiative requirements.